Diabetes is one of the most common metabolic disorders, and with our aging, sedentary and increasingly obese population, the number of affected individuals will continue to rise. This will have major implications for cardiological practice since much of the excess morbidity and mortality among diabetic patients is attributable to accelerated atherogenesis. Young diabetics are at particular risk and, by the age of 50 years, 33% of those requiring insulin have died from coronary heart disease. Indeed, 75% of all deaths in patients with diabetes are from this cause. Generally speaking, the management of diabetic patients with heart disease is underpinned by the same evidence base as applies to non-diabetic patients, and it is noteworthy that 15–20% of the patients in most of the landmark clinical trials have been diabetic. Recently, however, trials such as the UKPDS, HOPE, and DIGAMI studies (see below) have identified novel strategies for reducing cardiovascular risk in diabetes. These trials have already had a major impact on cardiological practice, emphasising the prime importance of blood pressure control and converting enzyme inhibition for reducing cardiovascular risk in diabetes, and also the value of insulin treatment for reducing mortality in diabetic myocardial infarction. Additional trials, already in progress, are expected to refine further the cardiovascular management of patients with diabetes in order to provide an effective challenge for a problem that shows no signs of going away.